New directives would mandate pain treatment for children in hospitals

Physicians will be required to give pain treatment to infants and children for routine procedures such as blood tests and simple wound sutures. Changes in how doctors view pain in children has lead the Israel Pediatric Association to formulate new recommendations on treating pain in children in hospitals.

The new instructions were formulated by a committee of specialists from the association in cooperation with the Israeli Association for Emergency Medicine as well as anesthetists and pain specialists. The new recommendations update Health Ministry directives from 2003 on minimizing pain for children, and are based on recent studies showing that infants and children experience pain at levels similar to adults. It was previously thought that children experience lower levels of pain. The new directives also engage with a number of other myths, for example that infants have no memory of pain or that delaying the treatment of pain in babies will strengthen them.

In addition, the new rules take advantage of new short-acting pain medications, which have fewer dangerous side effects. The recommendations also are based on the wider usage of medical monitoring equipment for vital signs such blood pressure and pulse outside of operating rooms, which enable more treatment for pain in the case of abnormal findings. The new rules also are partially a response to a report from February 2009 from the National Council for the Child that found failures in the treatment of pain for children in hospitals.

The committee, headed by Dr. Itai Shavit, director of the Pediatric Emergency Medicine Unit at the Rambam Medical Center in Haifa, recommended the introduction of new ways to measure pain in children aged three to eight, such as visual aids with faces to describe levels of pain. Children often exaggerate their pain; the recommendations are to repeat the measurements after a few minutes. Children, rather than medical personnel, should evaluate their own pain. A number of studies have proved that doctors and nurses tend to underestimate the amount of pain felt by children, Shavit said.

For children under the age of three medical staff must use external signs, including the strength of crying, rigidity of the body or limb movements, facial expressions and other behavioral signs, such appetite and sleep, to gauge the amount of pain they are feeling.

In addition to treating pain, the recommendations also require medical staff to deal with children's fears of medical treatment, which usually aggravates the pain they feel. This includes children's lack of understanding of the treatment, the injury and the cause of the pain.

The new rules are not legally binding, but have been adopted by all the Israel Medical Association's professional bodies, and similar instructions have received the status of binding regulations in court rulings.

The National Council for the Child report examined 22 Israeli hospitals and found that in most of them children are not treated adequately for pain in emergency rooms and pediatric wards, and that most hospitals do not deal adequately with children's pain. Only a few hospitals use topical anesthetics for children, and in 18 of the 22 hospitals the most painful treatments for infants over one year old were done without proper pain relief. Even in cases where proper pain evaluation was done in the emergency room, a second evaluation was often not done after the treatment - and fewer pain evaluations were done in pediatric wards than in the emergency room.

"The approach to pain in children has changed, and if in the past we related to pain as a marginal matter in treatment, today it is a central issue in the treatment framework," said Dr. Zachi Grossman, head of the Israel Pediatric Association.

Other recommendations include encouraging parents to stay with the child during all treatments, including taking blood, as well as providing parents with a quiet room in which they can calm very young children. Parents should be provided with toys or books to play with the child and distract them from the treatments. They can read books, play music or show movies on DVD players to their children

The new rules detail when to sedate children in the event of severe pain, including the use of nitrous oxide to relieve pain for short, painful steps such as wound suture, needle insertion, bandage changing and the insertion of medical devices. Laughing gas (nitrous oxide) is not considered appropriate for children who are uncooperative or for severe pain, and it can cause vomiting and other side effects.

There are recommendations for specific medical problems, such as migraines: The children and parents should be placed in a separate dark, quiet room, and be given anti-nausea drugs as well as sweetened liquids to prevent dehydration.